The use of extracorporeal membrane oxygenation (ECMO) to support the pregnant patient and fetus requires a complex decision-making process. Peripartum ECMO requires coordinated and informed decision-making between an interdisciplinary team of experts, incorporating the unique considerations and, at times, competing physiologic priorities of the pregnant patient. It is often confounded by a scarcity of local relevant experience engendered by its rare occurrence. No event has made the need for an organized approach to the utilization of ECMO in pregnant patients more pressing than the COVID pandemic. The conditions affecting pregnant patients that warrant ECMO consideration are high stakes and, at times, ethically challenging, although outcomes are favourable compared to the general population. This review provides background information and context, followed by a practical approach to the care and specific medical management of patients who are facing life-threatening conditions warranting ECMO while pregnant.